Median Blood Glucose Levels Research Articles

Association of Admission Hyperglycemia with Clinical Outcomes in Patients with Symptomatic Intracranial Hemorrhage After Endovascular Treatment for Large Vessel Occlusive Stroke.

Symptomatic intracranial hemorrhage (sICH) is a fatal complication after endovascular treatment (EVT) for acute large vessel occlusive (LVO) stroke. The aim of this study was to investigate the association between hyperglycemia and outcomes in patients with postprocedural sICH. Of the 2567 patients with AIS who underwent EVT from two large multicenter randomized trials and two prospective multicenter registry studies, 324 patients occurred sICH with documented admission glucose were included in this study. The primary outcome was functional independence (defined as a modified Rankin Scale score of 0 to 2) at 90 days. Secondary outcomes included mRS score of 0 to 3, 0 to 1, and mRS score at 90 days. Safety outcome was the mortality within 90 days. Admission hyperglycemia was defined as a plasma blood glucose ≥7.8 mmol/L (140 mg/dL) in our analysis. Of 324 eligible participants included in this study, hyperglycemia was observed in 130 (40.1%) patients. The median age was 67 (IQR, 58-75) years, and median blood glucose level was 7.1 (IQR, 6.0-9.3) mmol/L. After adjusting for confounding variables, admission hyperglycemia was associated with decreased odds of functional independence (adjusted odds ratio[OR] 0.34; 95% CI 0.17-0.68; P= 0.003), decreased odds of favorable outcome (adjusted OR 0.31; 95% CI 0.16-0.58; P < 0.001) and increased odds of mortality (adjusted OR 2.56; 95% CI 1.47-4.45; P = 0.001) at 90 days. After 1:1 propensity score matching analysis, the results were consistent with multivariable logistic regression analysis. In patients who suffered sICH after EVT for acute large vessel occlusive stroke, hyperglycemia is a strong predictor of poor clinical outcome and mortality at 90 days.

Impact of hospital-community diabetes management intervention in Central Region, Ghana: A retrospective study

ObjectiveEffective diabetes management remains suboptimal in low-resourced countries including Ghana. We determined the effectiveness of hospital-community link diabetes management intervention on glycaemic control and other outcomes. MethodsA retrospective study design, using secondary data from the Ghana-Netherlands for Health Foundation diabetes programme. The z-test was used for proportions, to compare parameters between baseline (2017) and endpoint (2022). The Friedman test was used to assess changes in blood glucose levels, and the multivariable Logistic regression to identify factors associated with blood glucose control. ResultsAnalyses of 251 clinical records showed decline in median blood glucose levels across six years from 8.8 mmol/L (7.2–12.9) in 2017 to 6.5 mmol/L (5.7–7.2) (p = 0.001) in 2022, recording 43 % increase in patients attaining glycaemic control in 2022 (p = 0.001). The Friedman test showed significant reduction in glucose levels (χ2 = 319.2, p = 0.001), with an effect size of 0.25 using the Kendall test. The logistic regression analyses revealed that patients on metformin and Glibenclamide combination were more likely to achieve glycaemic control than those on metformin monotherapy (adjusted OR = 7.30, 95 % CI 2.31–23.01, p = 0.001). ConclusionThe intervention achieved significant reduction in blood glucose levels. Patients with diabetes benefit from the hospital-community link diabetes management intervention regarding glycaemic control.

Is a high preoperative HbA1c level a risk factor for postoperative complications in patients with non-small-cell lung cancer?

PurposeDiabetes mellitus (DM) is a common comorbidity of lung cancer. We hypothesized that severe DM is associated with increased complications after surgical resection of non-small-cell lung cancer (NSCLC).MethodsA review of our retrospective thoracic database identified 1139 consecutive surgical resections for NSCLC from 2002 to 2021. Our analysis included the exploration of clinicopathological features, perioperative variables, and surgical outcomes.ResultsIn addition to lung cancer, 170 patients (14.9%) had DM. The patients included 132 (77.6%) men and 38 (22.4%) women, with a median age of 72 (range, 51–93) years old. The median preoperative fasting blood glucose and HbA1c levels were 135 mg/dL (range, 57–303) and 6.9% (range, 5.1–14.8), respectively. Eighty-one patients had DM as a single comorbidity, and 89 patients had other comorbidities or a relevant medical history. A total of 144 patients were prescribed these drugs. There were 107 patients (62.9%) who consulted a specialist diabetes endocrinology department preoperatively and 118 patients (69.4%) who required sliding-scale insulin during the perioperative period. Forty-seven patients (27.6%) developed post-operative complications. No cases of bronchopleural fistula were noted. A univariate analysis showed that the sex (p = 0.017), body mass index (BMI) (p = 0.0032), surgical procedure (p = 0.017), surgical time (p = 0.002), and lymphatic invasion (p = 0.011) were significantly different among patients stratified by postoperative complications. A multivariate analysis showed that a low BMI (odds ratio [OR]: 0.413, 95% confidence interval [CI]: 0.196–0.870, p = 0.018), long surgical time (OR: 2.690, 95% CI: 1.190–6.082, p = 0.015), and presence of lymphatic invasion (OR: 2.849, 95% CI: 1.319–6.135, p = 0.007) were risk factors for postoperative complications. In contrast, severe preoperative DM did not have a significant negative effect on the incidence of postoperative complications.ConclusionIn modern respiratory surgery, severe DM does not affect the short-term outcomes under strict preoperative treatment.

Correlational analysis between salivary and blood glucose levels in individuals with and without diabetes mellitus: a cross-sectional study

Objective To estimate the association of patient-related demographic, socioeconomic status, physical activity, stress, and dietary factors influencing the relationship between salivary and blood glucose levels in individuals with and without diabetes mellitus (DM). Method This cross-sectional study was conducted on 166 participants with and without DM. Saliva and blood were collected to estimate the glucose levels. Age, gender, occupation, socioeconomic and education level, BMI, hip to waist circumference, stress, dietary pattern, lifestyle, physical activity, family history of diabetes, and type of diabetes were recorded. The association of saliva to predict blood glucose levels was analysed using Spearman Rank Correlation and how these patient-related factors influence the correlation was estimated for future machine learning models. The difference in medians for various groups was calculated using the Mann-Whitney U Test or Kruskal Wallis Test. Results Blood glucose level is not significantly correlated to salivary glucose level. However, a statistically significant difference in the median blood glucose levels for diabetic participants (median = 137) compared to healthy controls (p-value < .05) was noted. The correlation between blood and salivary glucose was more positive for higher levels of glucose (Spearman 0.4). Age, alcohol consumption, monthly wages, intake of vegetables, and socioeconomic status affect blood glucose levels. Conclusion A correlation between saliva and blood glucose levels in healthy individuals was weak. Saliva should only be used as a monitoring tool rather than a diagnostic tool and is more reliable for patients with poorly controlled diabetes mellitus.

Hyperglycemia and insulin infusion in pancreatoduodenectomy: a prospective cohort study on feasibility and impact on complications.

Hyperglycemia is a risk factor for postoperative complications but its impact on outcome after pancreatoduodenectomy (PD) is scarcely studied. This prospective cohort study aimed to assess the effect of continuous insulin infusion on postoperative complications and blood glucose, as well as to evaluate the impact of hyperglycemia on complications, after PD. One hundred patients planned for PD at Skåne University Hospital, Sweden were prospectively included for perioperative continuous insulin infusion and a historic cohort of 100 patients was included retrospectively. Median blood glucose levels were calculated and data on complications were analyzed and compared between the historic cohort and the intervention group as well as between normo- and hyperglycemic patients. Median glucose levels were significantly lower in the intervention group compared to the historic cohort up to 30 days postoperatively (median glucose 8.5mmol/l (interquartile range 6.4-11) vs. 9.1mmol/l (interquartile range 6.8-17) ( P =0.007)). No significant differences in complication rates were recorded between these two groups. The incidence of complications classified as Clavien ≥3 was higher in hyperglycemic patients (100 vs. 27%, P =0.024). Among hyperglycemic patients the prevalence of preoperative diabetes was higher compared to normoglycemic patients (52 vs.12%, P <0.001). In patients with a known diagnosis of diabetes, a trend, although not statistically significant, towards a lower incidence of postoperative pancreatic fistula grade B and C, as well as postpancreatectomy hemorrhage grade B and C, was seen compared to those without preoperative diabetes (6.8 vs. 14%, P =0.231 and 2.3 vs. 7.0%, P =0.238, respectively). Insulin infusion in the early postoperative phase after PD is feasible in a non-ICU setting and significantly decreased blood glucose levels. The influence on complications was limited. Preoperative diabetes was a significant predictor of postoperative hyperglycemia and was associated with a lower incidence of clinically significant postoperative pancreatic fistula.

Association Between Admission Hyperglycemia and Outcomes After Endovascular Treatment in Acute Basilar Artery Occlusion.

Admission hyperglycemia and high admission blood glucose levels have been associated with poor outcomes in acute ischemic stroke. However, the relationship between admission hyperglycemia and outcomes after endovascular treatment (EVT) in acute basilar artery occlusion (ABAO) still remain unclear. This study aimed to investigate the association between admission hyperglycemia and clinical outcomes in ABAO following EVT. Patients from the BASILAR registry with admission blood glucose levels treated with EVT were included. We defined admission hyperglycemia as blood glucose levels≥7.8mmol/L. The primary outcome was favorable outcome [defined as a modified Rankin Scale score (mRS) of 0-3] at 90days, Secondary outcomes included other functional outcomes (mRS 0-2, mRS 0-1) at 90days, symptomatic intracerebral hemorrhage (sICH) within 48h, and mortality at 90days. Of 545 eligible patients included, the median age was 65 (IQR, 56-73) years, and median blood glucose level was 7.36 (IQR, 6.10-9.66) mmol/L. Multivariable logistic regression analysis showed that admission hyperglycemia was associated with decreased favorable outcome (mRS 0-3) (adjusted odds ratio=0.52; 95% CI 0.35-0.79; P=0.001), and increased mortality (adjusted odds ratio=2.67; 95% CI 1.82-3.91; P<0.001). Restricted cubic spline regression analysis showed that the blood glucose level had a non-linearity association with favorable outcome and mortality, and that there was no association between admission hyperglycemia and sICH. Our study suggest that admission hyperglycemia is associated with an increased risk of poor functional outcomes and mortality in patients with ABAO treated with EVT. Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), ChiCTR180001475.

Risk Factors for COVID-19 Associated Mucormycosis: The Ophthalmologist's Perspective.

The COVID-19 pandemic has led to a dramatic rise in the incidence of rhino-orbito-cerebral mucormycosis (ROCM) in India. The purpose of our report is to describe the prevalence of ROCM in the context of SARS-CoV-2 infection during the second Indian COVID-19 wave, as well as its diagnostics proceeding, and to discuss the challenges met in the time frame from the suspected diagnosis to the therapeutic decision in such patients. We conducted a retrospective multicentre case series study at six centres of Sudhalkar and Raghudeep group of hospitals in India. ROCM was confirmed in 38 (2.5%) of the 1546 patients admitted with SARS-CoV-2 infection. The average time to establish a diagnosis was 16 days. In total, 19 (50%) patients suffered from type 2 diabetes and were mostly treated with hypoglycaemic agents (in 90% of cases). The standard of care for SARS-CoV-2 management included systemic steroids therapy, intravenous remdesivir for 5 days, and concomitant prophylactic antibiotic therapy following admission. The median (IQR) blood glucose levels in all patients during the course of hospitalisation was 320 (250.5–375) mg/dl. A total of 16% of patients had an irreparable functional loss, and the mortality was 5%. We may hypothesise that excessive administration of antibiotics that profoundly affects human microbiota, coupled with poorly controlled glycaemia and unprotocolised haphazard steroid administration, contribute to a favourable setting for mucormycosis infections.

Abstract TP8: Sodium-glucose Cotransporter 2 Inhibitors Coupled With 40% Carbohydrate Diet Improve Hyperglycemia Safely And Soon In An Acute Stroke Stage

Introduction: Hyperglycemia must be improved in acute stroke patients. However, effective treatment has not been established. Hypothesis: Moderate-carbohydrate (carbo) diet and sodium-glucose cotransporter 2 (SGLT2) inhibitors can lower blood glucose level (BGL) safely and soon in patients with oral ingestion and normal renal function. Methods: For the retrospective observational study, we included patients who 1) were admitted within 24 h of stroke onset between Jan 2011 and March 2019, 2) had not undergone insulin therapy, 3) presented hemoglobin A1c ≥ 6.5%, BGL ≥ 11.1 mmol/L, and estimated glomerular filtration rate ≥ 60 mL/min/1.73m2 at admission, 4) took diet and drugs orally during hospitalization, and 5) underwent blood examination on the 6th day. We classified patients into three groups: 60% carbo diet without SGLT2 (C60 group); 40% carbo diet without SGLT2 (C40 group); 40% carbo diet with SGLT2 (C40-SGLT2 group). We calculated daily carbo intake and evaluated sulfonylurea (SU) use during hospitalization, median BGL and median HL at admission and on the 6th day in three groups. Results: Of 5724 stroke patients, 84 patients met our inclusion criteria. There were 26 patients in the C60 group, 22 in the C40 group, and 36 in the C40-SGLT2 group. In three groups, median age was 70, 62, and 68 years, respectively, median body mass index was 24.1, 25.1, and 24.3 kg/m2, respectively, median daily carbo intake was 195, 140, and 140 g (p&lt; 0.0001), respectively, 46%, 9%, and 0% of patients used SU (p&lt; 0.0001), respectively, median BGL at admission were 14.2, 14.6, and 14.4 mmol/L, respectively, median HL at admission were 42.4, 44.1, and 43.3%, respectively, median BGL on the 6th day were 7.9, 8.2, and 6.4 mmol/L (p= 0.0003), respectively, and median HL on the 6th day were 40.5, 41.7, and 40.5%, respectively. BGL on the 6th day was decreased in three groups, and it was the most improved in the C40-SGLT2 group. BGL on the 6th day was not different between C60 and C40 groups; however, SU was seldom used in the C40 group. No dehydration occurred. Conclusion: SU was seldom necessary for the C40 group and unnecessary for the C40-SGLT2 group. SGLT2 inhibitors coupled with 40% carbo-diet lowered BGL safely and soon in patients with oral ingestion and normal renal function.

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

BackgroundOne possible reason for increased mortality due to SARS-CoV-2 in patients with diabetes is from the complication of diabetic ketoacidosis (DKA).ObjectivesTo re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA.DesignA systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.MethodsElectronic databases (Proquest, Medline, Embase, Pubmed, CINAHL, Wiley online library, Scopus and Nature) were searched from 1 December 2019 to 30 June 2021 in the English language using the following keywords alone or in combination: COVID-19 OR SARS-CoV-2 AND diabetic ketoacidosis OR DKA OR ketosis OR ketonemia OR hyperglycaemic emergency OR hyperglycaemic crisis. We included studies in adults and children of all ages in all healthcare settings. Binary logistic regression model was used to explore the effect of various demographic and biochemical parameters variables on patient’s final treatment outcome (survival or death).ResultsOf the 484 papers that were identified, 68 articles were included in the systematic review and meta-analysis (54 case report, 10 case series, and 4 cohort studies). Studies involving 639 DKA patients with confirmed SARS-CoV-2 [46 (7.2%) were children and 334 (52.3%) were adults] were analyzed. The median or mean patient age ranged from < 1 years to 66 years across studies. Most of the patients (n = 309, 48.3%) had pre-existing type 2 diabetes mellitus. The majority of the patients were male (n = 373, 58.4%) and belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity. The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399–638 mg/dl], 11.4% [IQR 9.9–13.5%], 7.16 [IQR 7.00–7.22], 10 mmol/l [IQR 6.9–13 mmol/l], and 24.5 mEq/l [18–29.2 mEq/l]; respectively. Mortality rate was [63/243, 25.9%], with a majority of death in patients of Hispanic ethnicity (n = 17, 27%; p = 0.001). The odd ratios of death were significantly high in patients with pre-existing diabetes mellitus type 2 [OR 5.24, 95% CI 2.07–15.19; p = 0.001], old age (≥ 60 years) [OR 3.29, 95% CI 1.38–7.91; p = 0.007], and male gender [OR 2.61, 95% CI 1.37–5.17; p = 0.004] compared to those who survived.ConclusionDKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [≥ 60 years old], male gender, BMI ≥ 30, blood glucose level > 1000 mg/dl, and anion gap ≥ 30 mEq/l.

Absence of Stress Hyperglycemia Indicates the Most Severe Form of Blunt Liver Trauma.

Background: Stress hyperglycemia is common in trauma patients. Increasing injury severity and hemorrhage trigger hepatic gluconeogenesis, glycogenolysis, peripheral and hepatic insulin resistance. Consequently, we expect glucose levels to rise with injury severity in liver, kidney and spleen injuries. In contrast, we hypothesized that in the most severe form of blunt liver injury, stress hyperglycemia may be absent despite critical injury and hemorrhage. Methods: All patients with documented liver, kidney or spleen injuries, treated at a university hospital between 2000 and 2020 were charted. Demographic, laboratory, radiological, surgical and other data were analyzed. Results: A total of 772 patients were included. In liver (n = 456), spleen (n = 375) and kidney (n = 152) trauma, an increase in injury severity past moderate to severe (according to the American Association for the Surgery of Trauma, AAST III-IV) was associated with a concomitant rise in blood glucose levels independent of the affected organ. While stress-induced hyperglycemia was even more pronounced in the most severe forms (AAST V) of spleen (median 10.7 mmol/L, p < 0.0001) and kidney injuries (median 10.6 mmol/L, p = 0.004), it was absent in AAST V liver injuries, where median blood glucose level even fell (5.6 mmol/L, p < 0.0001). Conclusions: Absence of stress hyperglycemia on hospital admission could be a sign of most severe liver injury (AAST V). Blood glucose should be considered an additional diagnostic criterion for grading liver injury.

Incidence and Impact of Dysglycemia in Patients with Sepsis Under Moderate Glycemic Control.

Glycemic control strategies for sepsis have changed significantly over the last decade, but their impact on dysglycemia and its associated outcomes has been poorly understood. In addition, there is controversy regarding the detrimental effects of hyperglycemia in sepsis. To evaluate the incidence and risks of dysglycemia under current strategy, we conducted a preplanned subanalysis of the sepsis cohort in a prospective, multicenter FORECAST study. A total of 1,140 patients with severe sepsis, including 259 patients with pre-existing diabetes, were included. Median blood glucose levels were approximately 140 mg/dL at 0 and 72 h indicating that blood glucose was moderately controlled. The rate of initial and late hyperglycemia was 27.3% and 21.7%, respectively. The rate of early hypoglycemic episodes during the initial 24 h was 13.2%. Glycemic control was accompanied by a higher percentage of initial and late hyperglycemia but not with early hypoglycemic episodes, suggesting that glycemic control was targeted at excess hyperglycemia. In nondiabetic patients, late hyperglycemia (hazard ratio, 95% confidence interval; P value: 1.816, 1.116-2.955, 0.016) and early hypoglycemic episodes (1.936, 1.180-3.175, 0.009) were positively associated with in-hospital mortality. Further subgroup analysis suggested that late hyperglycemia and early hypoglycemic episodes independently, and probably synergistically, affect the outcomes. In diabetic patients, however, these correlations were not observed. In conclusion, a significantly high incidence of dysglycemia was observed in our sepsis cohort under moderate glycemic control. Late hyperglycemia in addition to early hypoglycemia was associated with poor outcomes at least in nondiabetic patients. More sophisticated approaches are necessary to reduce the incidence of these serious complications.

EFFECT OF ESCITALOPRAM ON GLYCAEMIC CONTROL IN TYPE 2 DIABETES MELLITUS PATIENTS WITH DEPRESSION

Background: Depression is more common in patients with type 2 Diabetes Mellitus (DM) than pa­tients without type 2 DM. The objective of this study was to study the effect of escitalopram on gly­caemic control in type 2 diabetic patients with depression. Methods: This longitudinal study was conducted in Universal College of Medical Sciences (UCMS), Bhairahawa from September 2019 to March 2020. A total of 137 patients visiting internal medicine OPD and diagnosed with type 2 DM were included. The patients were then referred for psychiatric evaluation. Patient Health Questionnaire -9 was used for the assessment of depression by the con­sultant psychiatrist. A score of ≥5 was considered as depression. Participants were divided into two groups: Group 1 represented type 2 diabetic patients with depression (n=37) and group 2 without depression (n=100). Escitalopram 10mg daily was prescribed for group 1 patients, keeping the man­agement of DM unchanged for all. The fasting and postprandial blood glucose levels were measured at baseline, two weeks, four weeks, and six weeks interval, respectively, using the automated analyzer. Results: After the treatment with escitalopram, there was significant (p&lt;0.05) reduction in fasting and postprandial blood glucose level in subsequent weeks compared to baseline values. The fasting baseline median blood glucose level in group1 patients reduced from the value of 190.0 to 126.5 mg/ dl and postprandial median blood glucose level reduced from baseline value of 295.0 to 201.5 mg/dl at 6 weeks respectively. Conclusions: Treatment with escitalopram showed a favorable glycemic profile in type 2 DM patients with depression.

Accumulation of advanced glycation end products (AGEs) is associated with the severity of aortic stenosis in patients with concomitant type 2 diabetes

BackgroundAccumulation of advanced glycation end products (AGEs) leads to chronic glycation of proteins and tissue damage, particularly in patients with diabetes mellitus (DM). We aimed to evaluate whether increased accumulation of AGEs in patients with aortic stenosis (AS) and concomitant type 2 diabetes (DM) is associated with AS severity.MethodsWe prospectively enrolled 76 patients with severe AS (47.1% males; nonDM), aged 68 [66–72] years, and 50 age-matched DM patients with a median blood glucose level of 7.5 [5.9–9.1] mM and glycated hemoglobin (HbA1c) of 6.8 [6.3–7.8]%, scheduled for aortic valve replacement. Valvular expression of AGEs, AGEs receptor (RAGE), interleukin-6 (IL-6), and reactive oxygen species (ROS) induction were evaluated ex vivo by immunostaining and calculated as the extent of positive immunoreactive areas/total sample area. Plasma levels of AGEs and soluble RAGE (sRAGE) were assessed by ELISAs.ResultsSubjects with DM had increased valvular expression of both AGEs (6.6-fold higher, 15.53 [9.96–23.28]%) and RAGE (1.8-fold higher, 6.8 [4.9–8.45]%) compared to nonDM patients (2.05 [1.21–2.58]% and 2.4 [1.56–3.02]%, respectively; both p < 0.001). Plasma levels of AGEs (12-fold higher) and sRAGE (1.3-fold higher) were elevated in DM patients, compared to nonDM (both p < 0.0001). The percentage of valvular ROS-positive (2.28 [1.6–3.09] vs. 1.15 [0.94–1.4]%, p < 0.0001) but not IL-6-positive areas was higher within DM, compared to nonDM valves. In DM patients, the percentage of valvular AGEs- and RAGE-positive areas correlated with HbA1c (r = 0.77, p < 0.0001 and r = 0.30, p = 0.034). Similarly, plasma AGEs and sRAGE levels were associated with HbA1c in the DM group (r = 0.32, p = 0.024 and r = 0.33, p = 0.014, respectively). In all DM patients, we found an association between the amount of valvular AGEs and the disease severity measured as aortic valve area (AVA; r = 0.68, p < 0.0001). Additionally, in DM patients with HbA1c > 7% (n = 24, 48%) we found that valvular expression of AGEs correlated with mean transvalvular pressure gradient (PGmean; r = 0.45, p = 0.027). Plasma AGEs levels in the whole DM group correlated with AVA (r = − 0.32, p = 0.02), PGmean (r = 0.31, p = 0.023), and PGmax (r = 0.30, p = 0.03).ConclusionsOur study suggests that poorly-controlled diabetes leads to increased AGEs and RAGE valvular accumulation, which at least partially, might result in AS progression in DM patients.

3D kernel-density stochastic model for more personalized glycaemic control: development and in-silico validation

BackgroundThe challenges of glycaemic control in critically ill patients have been debated for 20 years. While glycaemic control shows benefits inter- and intra-patient metabolic variability results in increased hypoglycaemia and glycaemic variability, both increasing morbidity and mortality. Hence, current recommendations for glycaemic control target higher glycaemic ranges, guided by the fear of harm. Lately, studies have proven the ability to provide safe, effective control for lower, normoglycaemic, ranges, using model-based computerised methods. Such methods usually identify patient-specific physiological parameters to personalize titration of insulin and/or nutrition. The Stochastic-Targeted (STAR) glycaemic control framework uses patient-specific insulin sensitivity and a stochastic model of its future variability to directly account for both inter- and intra-patient variability in a risk-based insulin-dosing approach.ResultsIn this study, a more personalized and specific 3D version of the stochastic model used in STAR is compared to the current 2D stochastic model, both built using kernel-density estimation methods. Fivefold cross validation on 681 retrospective patient glycaemic control episodes, totalling over 65,000 h of control, is used to determine whether the 3D model better captures metabolic variability, and the potential gain in glycaemic outcome is assessed using validated virtual trials. Results show that the 3D stochastic model has similar forward predictive power, but provides significantly tighter, more patient-specific, prediction ranges, showing the 2D model over-conservative > 70% of the time. Virtual trial results show that overall glycaemic safety and performance are similar, but the 3D stochastic model reduced median blood glucose levels (6.3 [5.7, 7.0] vs. 6.2 [5.6, 6.9]) with a higher 61% vs. 56% of blood glucose within the 4.4–6.5 mmol/L range.ConclusionsThis improved performance is achieved with higher insulin rates and higher carbohydrate intake, but no loss in safety from hypoglycaemia. Thus, the 3D stochastic model developed better characterises patient-specific future insulin sensitivity dynamics, resulting in improved simulated glycaemic outcomes and a greater level of personalization in control. The results justify inclusion into ongoing clinical use of STAR.

Five‐Year Incidence of Hospital‐Based Emergencies Related to Acute Recreational Intoxication in Minors

Alcohol or other drug (AOD) intoxication in minors is a public health challenge. We characterized underage patients admitted to an emergency department (ED) with acute, recreational AOD intoxication. We conducted a 5-year (2012 to 2016) analysis of minors admitted to the only hospital-based pediatric ED in an urban area. Episodes of AOD intoxication were selected using ICD-9-CM diagnostic codes. Sociodemographics, substance use and clinical characteristics, laboratory parameters, and discharge dispositions were collected through the revision of clinical charts. A total of 266 admissions related to recreational AOD intoxication in 258 patients occurred during the study period. Among the 258 patients, 127 (49.2%) were men, median age 16years [IQR: 15 to 17years], and 234 (90.7%) of episodes were alcohol-related. At admission, 202/256 (78.9%) patients had a Glasgow Coma Scale≥13 points, the median systolic and diastolic blood pressure was 109mmHg (IQR: 101 to 118mmHg) and 67mmHg (IQR: 60 to 73mmHg), respectively, and the median blood glucose level was 112mg/dl (IQR: 99 to 127mg/dl). Only 72/258 (27.9%) patients underwent urine screening (22/72 (30.5%) were positive for cannabis), and only 30/258 (11.6%) were tested for blood ethanol (median: 185mg/dl, IQR: 163 to 240mg/dl). There was a trend in admissions occurring early in the morning of weekend days, and 249 (96.5%) patients were discharged home the day of admission. Though the severity of AOD intoxication seems to be mild to moderate, assessment of substance exposure is low and may underestimate polydrug use in underage populations.

STAR-Liège Clinical Trial Interim Results: Safe and Effective Glycemic Control for All.

While the benefits of glycemic control for critically ill patients are increasingly demonstrated, the ability to deliver safe, effective control to intermediate target ranges is widely debated due to the increased risk of hypoglycemia. This study analyzes interim clinical trial results of the fully computerized model-based Stochastic TARgeted (STAR) glycemic control framework at the University Hospital of Liège, Belgium. Patients with dysglycemia were randomly assigned to the full version of STAR, modulating both insulin and nutrition inputs, or STAR-IO, an insulin only version of STAR. Both arms target the normoglycemic 80-145 mg/dL (4.4-8.0 mmol/L) band. Results are further compared to retrospective data from 20 patients under the standard unit protocol targeting a higher 100-150 mg/dL (5.6-8.3 mmol/L) band. Much higher time in target band is provided under the full version of STAR, with similar safety and significantly lower incidence of mild hyperglycemia (blood glucose > 145 mg/dL or 8.0 mmol/L) and severe hyperglycemia (blood glucose > 180 mg/dL or 10.0 mmol/L). As a result, lower median blood glucose levels are safely and consistently achieved with lower glycemic variability, suggesting STAR's potential to improve clinical outcomes. These interim results show the possibility to achieve safe, effective control for all patients using STAR, and suggest glycemic control to lower targets could be beneficial.

The effects of expressing antenatal colostrum in women with diabetes in pregnancy: A retrospective cohort study.

Some women with diabetes in pregnancy express and store colostrum in the antenatal period for the purposes of preventing and treating neonatal hypoglycaemia. Our primary aim was to compare rates of neonatal hypoglycaemia in babies born to mothers who express and store antenatal colostrum to babies born to mothers who do not. Retrospective cohort study involving 357 women with diabetes in pregnancy, who had live, singleton births delivered after 36weeks gestation, in a regional hospital in North Queensland (2014-2015). Multivariable binary logistic regression modelling identified independent characteristics associated with primary outcomes. Eighty women (23%) expressed antenatal colostrum and 223 (62%) did not. One hundred and thirty-one babies (37%) were diagnosed with hypoglycaemia. Aboriginal and Torres Strait Islander women were less likely to express than Caucasian women (odds ratio (OR) 0.10, 95% confidence interval (CI) 0.01-0.77). There were no significant differences in the rates of hypoglycaemia, or median blood glucose levels in babies born to mothers who expressed antenatal colostrum compared to babies born to mothers who did not express. Babies born to mothers who expressed were significantly less likely to receive formula in hospital compared to babies born to mothers who did not (OR 0.12, 95% CI 0.05-0.32). We found no independent association of expressing antenatal colostrum on rates of neonatal hypoglycaemia or median blood glucose levels. Expressing antenatal colostrum may have some benefits to the newborn such as reduced formula consumption in hospital. Further research into other methods of reducing neonatal hypoglycaemia appears warranted.

Current state of sedation, analgesia and blood glucose management in intensive care units of county hospitals: a multicenter cross-sectional survey in Guizhou Province of China

To investigate the current state of sedation, analgesia and blood glucose management in intensive care units (ICUs) of county hospitals in Guizhou Province of China, and to provide the evidences for improving quality control in critical care medicine. In March 2018, 3-4 ICUs of hospitals in every prefecture (one hospital per county) in Guizhou Province were visited to do the field survey. The patients' nursing records within 24 hours after ICU admission were reviewed, and the information such as gender, age, major diagnosis at the ICU admission, the time of admission, were collected. Moreover, the conditions about sedation and analgesia drug use and monitoring, blood pressure, blood glucose as well as and the usage of insulin and ventilator were recorded. Because not all the needed information of every ICU or patient was obtained, only the numbers of the ICUs and patients whose required information had been obtained were analyzed. Twenty-eight county hospitals in nine prefectures of Guizhou Province and 152 ICU patients were surveyed. There was a median of 5 (4, 7) patients stayed in every ICU on the day of survey. A total of 152 patients were enrolled, with 102 male (67.1%) and 50 female (32.9%); the median age was 65.0 (51.5, 74.8) years old; the major diagnosis at ICU admission was mainly cerebral diseases which accounted for 50.0% (76/152), and the second place was digestive system diseases which accounted for 13.8% (21/152); 53.8% (78/145) of patients were admitted to ICUs during 08:00-18:00. The percentages of ICUs which had patients received sedation and analgesia were 92.6% (25/27) and 88.9% (24/27) respectively, while only 44.4% (12/27) and 18.5% (5/27) of them were evaluated the depth of sedation and the level of pain respectively. There was 49.0% (71/145) of patients received sedation, and 33.8% (24/71) of them was evaluated by sedation scores; 49.7% (72/145) of patients received analgesia, and 13.9% (10/72) of them were evaluated by pain scores. The proportions of invasive mechanical ventilation in the patients with sedation or analgesia were both higher than those in the patients without sedation or analgesia [sedation compared with non-sedation: 85.9% (61/71) vs. 21.6% (16/74), analgesia compared with non-analgesia: 87.5% (63/72) vs. 19.2% (14/73), both P < 0.01]. The incidence of hypotension was similar between the sedated patients and the non-sedated patients [55.9% (38/68) vs. 40.3% (29/72), P > 0.05], while the incidence of hypotension was higher in the patients with analgesia as compared with that in the patients without analgesia with significant difference [56.9% (41/72) vs. 38.2% (26/68), P < 0.05]. Within 24 hours after ICU admission, there were 40.7% (59/145) and 5.5% (8/145) of patients had hyperglycemia (random blood glucose level ≥ 11.1 mmol/L) or hypoglycemia (random blood glucose level ≤ 3.9 mmol/L) respectively. No insulin was used to control the blood glucose level in the patients who had hypoglycemia or did not have hyperglycemia. However, only 23.7% (14/59) of patients with hyperglycemia were treated with insulin, the initiation of insulin therapy was triggered when median blood glucose level was 19.8 (16.8, 24.5) mmol/L. The evaluation of analgesia and sedation in the ICUs of county hospitals in Guizhou Province was seriously inadequate and needed to be strengthened urgently. Moreover, the strategy of blood glucose management was also needed to be improved.

Non-islet-cell tumour hypoglycaemia (NICTH): About a series of 6 cases

The purpose of this study was to analyse the characteristics of 6 patients managed in a university hospital between 1996 and 2016 for non-islet cell tumor hypoglycemia (NICTH), a form of hypoglycaemia due to the paraneoplastic secretion of IGF-2 or its related substances. ResultsThree of these 6 patients (50%), aged over 69 years, including 2 with acromegaloid phenotype, presented with a pleural solitary fibrous tumor (SFT), with median diameter 20 cm (interquartile range, 12.5–20.5) with a low median SUV (3.3 g/mL (QR, 2–7.5)) on 18F-FDG PET. The other 3 patients presented respectively neuroendocrine carcinoma (NEC) of the palate (70-year-old woman), retroperitoneal myxofibrosarcoma (66-year-old man) and meningeal hemangiopericytoma (36-year-old woman). All 3 were inoperable and did not respond to any therapy other than glucose solution. Corticosteroid therapy was effective in the 3 SFTs and the NEC. One of the SFTs recurred 10 years later with asymptomatic hypoglycemia, which resolved after reintervention. Median (IQR) blood glucose levels of the 6 patients was 0.4g/L (QR, 0.31–0.41), with hypoinsulinemia at 0.7mIU/L (QR 0.7–2.0), undetectable GH, low IGF-1, normal IGF-2 level in 5/6 cases, a high IGF-2:IGF-1 ratio at 26.9 (QR, 20.8–37.8), hypokalemia and hypomagnesemia. ConclusionNICTH is a rare syndrome, which should be considered in the presence of hypoinsulinemic hypoglycemia with low GH and IGF-1, and a IGF-2:IGF-1 ratio>10. Corticosteroid therapy was effective in elderly subjects, particularly with solitary fibrous tumor, which was generally operable. Hemangiopericytoma and myxofibrosarcoma had poor prognosis in younger patients.

Association between Blood Glucose Levels the Day after Targeted Temperature Initiation and Outcome in Traumatic Brain Injury: A Post-Hoc Analysis of the B-HYPO Study.

We investigated associations between blood glucose levels and clinical outcomes in participants of the multi-center randomized controlled Brain-Hypothermia (B-HYPO) study. Patients with severe traumatic brain injury (TBI, Glasgow Coma Scale 4-8) were assigned to therapeutic hypothermia (TH, 32-34°C, n = 98) or fever control (35.5-37.0°C, n = 50) groups. TH patients were cooled as soon as possible for ≥72 h and rewarmed at a rate of <1°C/d. We recorded blood glucose (BG) levels on days 0, 1, and 3 after treatment initiation, and day 1 after rewarming. The Glasgow Outcome Scale was assessed at 6 months. Median BG levels decreased from day 0 to day 1 (163 vs. 132 mg/dL, p = 0.0062) in the fever control group. In contrast, a decrease was observed from day 1 to day 3 (157.5 vs. 126 mg/dL, p < 0.001) in the TH group. Day 1 BG was higher in the TH group compared with the fever control group (p = 0.0252). At day 0, BG levels were higher in non-survivors compared with survivors across all patients (p = 0.0035), the TH group (p = 0.0125), and the non-surgical group (p = 0.0236). Higher day 1 BG levels were observed in non-survivors compared with survivors across all patients (p = 0.0071), the fever control group (p = 0.0495), and the surgical group (p = 0.0364). In the TH group, the initial stress hyperglycemia was sustained the next day after TH induction. Day 1 BG predicted outcome in TBI patients with TH and fever control. Our findings indicate the significance of BG control particularly during TH treatment.